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Shortened Arch

Shortened Arch

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Published by: Jason Lee on Jun 21, 2012
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The shortened dental arch: A review of the literature
Debora Armellini, DDS, MS,
and J. Anthony von Fraunhofer, MSc, PhD
School of Dentistry, University of Maryland, Baltimore, Md
The functional demands of patients are highly variable and individual, requiring dental treatment to betailored to the individual’s needs and adaptive capability. The World Health Organization indicates that a functional, esthetic, natural dentition has at least 20 teeth, while the literature indicates that dentalarchescomprising theanteriorandpremolarregionsmeet therequirementsofafunctionaldentition.TheEnglish-language peer-reviewed literature pertaining to the short dental arch (SDA) was identifiedthrough the Medline search engine covering the period between 1966 and the present and critically reviewed. This treatment option for the partially dentate patient may provide oral functionality,improved oral hygiene, comfort, and, possibly, reduced costs.
(J Prosthet Dent 2004;92:531-5.)
o provide care for the partially-dentate or edentu-lous patient, the dentist must consider a number of factors, such as oral functionality, vertical dimension,occlusion, maintenance of hard tissue, and temporo-mandibular joint health, as well as patient comfort.The weight accorded each factor varies with the patientandtheproposedtreatment,butaquestionthatremainsis how many teeth are needed to satisfy functionaldemands.
Oral functionality 
is defined in this article asthe maintenance of masticatory ability and efficienc y  while preserving the health of soft and hard tissues.
Forthepartiallydentatepatientwithseveralposteriorteeth,thedentistmaydesignafixedorremovablepartialdenture(FPDorRPD),incorporating1ormorenaturalteeth. When the first or second molars are present, they are usually incorporated into the prosthesis design, butit is unclear whether this is necessary to maintain oralfunctionality. In other words, should the occlusal tablebe extended to the first and second molar teeth? A lon-ger occlusal table may be achieved with implant-supported restorations by posterior placement of theimplant, but this usually is limited to the first molar po-sition. With implant-supported restorations, it is possi-ble to achieve posterior occlusion by cantileverextensions, although this should be limited to6 to 8mminthemaxillaand10mminthemandible.
Itisun-clear from the dental literature whether this extension iseither necessary or justified.Dentists replace missing, damaged, and severely de-cayed teeth by fixed or removable prostheses to restoreorimprovemasticatoryfunction.Thereisafundamentalquestion in any treatment plan, namely, the desirable/mandatory length of an occlusal table. There have been various references in the literature to the concept of theshort dental arch (SDA) as a defined treatment optionfor the partially dentate patient. While many dentistsmay accept that restoring the complete dental arch isnot always necessary, there still is the need to providethe patient with an affordable and functional treatment,a need satisfied by the short dental arch. The English-language, peer-reviewed literature pertaining to theshort dental arch (SDA) was identified through theMedline search engine covering the period between1966 and the present and critically reviewed. This treat-ment option for the partially dentate patient offers thebenefits of oral functionality, improved oral hygiene,comfort, and possibly reduced costs.
Oral functionality 
The literature indicates that masticatory ability isclosely related to the number of teeth, and there is im-paired masticatory ability when the patient has less than20 well-distributed teeth.
In this context, the short-ened dental arch (SDA) may be defined as having an in-tact anterior region butareduced number of occludingpairs of posterior teeth.
In 1992, the World Health Organization stated thatthe retention, throughout life, of a functional, esthetic,natural dentition of not less than 20 teeth and not re-quiring recourse to prostheses should be the treatmentgoal for oral health.
It is not possible, however, toquantifytheminimumnumberofteethneededtosatisfy functional demands because these demands vary fromindividual to individual. Furthermore, both dental andfinancialconsiderationsstronglyinfluencethetreatmentplan, and, in fact, dental arches comprising the anteriorand premolar regions meet the requirements of a func-tional dentition.
It follows that the replacement of missing molar teeth by cantilevers, resin-bonded fixedpartialdentures,implant-supportedprostheses,ordistalextension removable partial dentures may amount toover-treatmentforpatientswithshorteneddentalarches.
Masticatory efficiency 
Masticatory efficiency and masticatory ability are im-portant components of oral functionality, but patientadaptation to changes in dental arch length with pro-gressive loss of teeth is critical to successful treatment.The literature on masticatory efficiency and masticatory 
Assistant Professor, Department of Restorative Dentistry.
Professor, Department of Oral and Maxillofacial Surgery.
abilityoverthepast50to60yearscanbeseparatedinto2broad categories, subjective and objective evaluations.
Subjective masticatory function or masticatory ability usually is evaluated through interviews with patients as-sessing their own masticatory functionality. Objectiveevaluation of masticatory function or masticatory effi-ciencycommonlyinvolvesmeasurementofthepatient’sabilitytogrindfood.Overall,theliteratureindicatesthatmasticatory ability closely correlates with the number of teeth and is impaired when there are fe w er than 20 uni-formly distributed teeth in the mouth.
The correlation between the dental arch length andmasticatoryefficiencyisinfrequentlyaddressedinthelit-erature.Anearlystudyinvolvedacross-sectionalclinicalinvestigationof118patientsseparatedinto6groupsac-cording to the length and symmetry of the shorteneddental arch.
Two patterns of change in oral function were identified. In 1 group, masticatory efficiency changed slowly until the dentition had been reducedto 4 occlusal units and, thereafter, decreased rapidly.In the second group, masticatory efficiency changedprogressively at a quasi-uniform rate. The authors sug-gested that there is sufficient adaptive capacity for pa-tients to maintain adequate oral function in shorteneddental arches provided at least 4 occlusal units remain,although these must be symmetrically placed. Another study compared patient perceptions relatedto masticatory efficiency in 43 subjects with SDAs withthe findings from 54 patients with complete dentitions.The results indicated that while masticatory function,food perception, food selection, and actual food con-sumption were affected for SDA patients, the perceivedreduction was acceptable to the patients.
In another study, the oral functionality for patients with shortened dental arches was compared with thatfor patients with dental arches lengthened by distalextension removable partial dentures.
No significantdifferences were found in the oral functionality of sub- jects with SDAs and those who wore RPDs. Overall,the findings of the study suggested that oral function-ality was not improved for SDA patients when provided with a distal extension RPD, and most complaintsappeared to be related to esthetics due to missing pos-terior teeth. A more recent study 
compared the masticatory abil-ities of Tanzanian subjects with shortened dental archestothoseofadultswithcompletedentalarches.TheSDA patientshad0to8pairsofoccludingposteriorteethanddiffered in arch length and arch symmetry. Masticatory ability was assessed subjectively through perceived diffi-culties in masticating 20 common Tanzanian foods.Patients with very shortened arches, 0 to 2 pairs of oc-cludingpremolars,hada95%to98%prevalenceofcom-plaints and the greatest difficulties in mastication. Incontrast, the prevalence of complaints was only 3% to5% for subjects with intact premolar regions and at least1pairofoccluding molars.Othercategoriesofsubjects,that is, those with different numbers of premolar andmolar teeth, reported an intermediate volume of com-plaints (33% to 54%). The study noted that there wasan inverse relationship between the perceived difficulty of mastication and the decrease in the number of pairsof occluding teeth; thus, for example, subjects with0 to 2 pairs of occluding premolars had severely limitedmasticatory ability. Likewise, subjects with asymmetricarches and unevenly distributed teeth reported greatermasticatory difficulty than subjects with more completedentalarches.Anydifferencesinmasticatoryabilitywereexacerbated with harder foods.Overall,ifthepremolarregionsareintactandthereisatleast1pairofoccludingmolars,theauthorsconcludedthat an SDA does not impair masticatory efficiency. Incontrast, there is severely impaired masticatory ability  when the patient has a reduced number of occludingpremolarsand/or asymmetric arches, especially withhard foods.
It has been reported by some authors, however, thatSDAs do not lead to alterations in food selection al-though patients only have sufficient masticatory ability  when 20 or more ‘‘well distributed’’ teeth remain, thatis, when anterior and premolar teeth are present.
Thus, impaired masticatory ability and associatedchanges or shifts in food selection are manifested only  when there are less than 10 pairs of occluding teeth.
Prosthodontic considerations
Prosthodontic considerations in patient treatmentincludeocclusalstability,establishingthecorrectverticaldimension, and preserving the health of the soft andhard tissues as well as that of the temporomandibular joint. While occlusal stability can be defined as the ab-sence of the tendency for teeth to migrate other thanthe normal physiologic compensatory movements oc-curringovertime,
abetterdefinitionmaybethesta-bility of tooth positioning relative toits spatialrelationship in the occluding dental arches.
Occlusalstability isdetermined by anumber offactors, includingperiodontal support, the number of teeth in the dentalarches, the interdental spacing, occlusal contacts, andtooth wear. Typically,there istooth mobility, toothmi-gration, and supra-eruption ofunopposedteethwhen1ormoreteetharemissingfromanarch.Distaltoothmi-gration occurs in SDAs, and this may result in an in-creased anterior load which, in turn, increases thenumber and intensity of anterior occlusal contacts as wellastheinterdentalspacing.
Sucheffectsmaybeex-acerbated when unopposed teeth and lone-standingteeth have inadequate periodontal support. Likewise,tooth migration can cause changes in the vertical andhorizontal overlap, occlusal wear, and loss of posteriorsupport, among other effects.
 Although it is widely believed that changes inocclusal balance cause tooth movement, migration,and supra-eruption, few studies have addressed the re-lationship between shortened dental arches and occlu-sal stability. Occlusal stability is thought to be reduced with extremely short dental arches, that is, only 0 to 2pairs of occluding premolars. While occlusal stability isreported to be greater with longer dental arches, thatis, 3 to 4 occluding units, older patients generally experience increased changes in occlusal integrity.
Overall, SDAs comprising anterior and premolar teethsatisfy oral functional demands and show similar vertical overlap and occlusal tooth wear patterns tothose found with complete dental arches.
 Whilepatients with SDAs have more interdental premolarspacing, greater occlusal contact of anterior teeth,and lower alveolar bone scores (that is, the alveolarbone height at the distal surface of each premolar
),the differences in dentition and occlusal characteristicsfrom those of complete or longer dental arches appearto change little over time.
This suggests that theSDA, in fact, is characterized by long-term occlusal sta-bility.Fewstudiesarereportedontheprevalenceoftempo-romandibular joint (TMJ) problems in adults withshortened dental arches. A study compared SDsubjects with an intact anterior region and 0 to 8 poste-rioroccludingpairsofteethwithacontrolgrouphavingcomplete dental arches.
The study reported a greaterprevalenceofjointsoundswithsubjectshavingonlyuni-lateral posterior support and those with no posteriorsupport. However, there were no differences in pain,mandibular mobility, maximum mouth opening, orclicking/crepitation of the joints for the SDA and con-trol groups. It was noted, however, that tooth wear in-creased significantly with decreased posterior support. While there was no evidence that SDAs provoke TMJproblems, it was noted that the risk for pain and jointsounds increasedwhen unilateral or bilateral posteriorsupport is missing.
 Another study addressed the question of whetherSDAs could cause functional overloading of the teethand TMJ, effects possibly leading to periodontal diseaseand TMD.
Electromyographic masticatory musclestudies were used to calculate occlusal forces and jointloads using a finite element jaw model and comparedthese values with actual measured occlusal forces. While the occlusal force on each tooth increased withmissingmolarocclusion,thereappearedtobeanoveralldecrease in joint loads, although the occlusal force perroot surface area was always greatest on the most poste-rior tooth. There were no indications that an SDA cancause overloading of the TMJ or the teeth, suggestingthat neuromuscular regulatory systems are efficient incontrolling themaximumclenchingforceundervariousocclusal conditions.
Patient comfort 
Patients must adapt functionally and psychosocially to dentures, and some may never achieve this goal. Asa result, while the inserted prosthesis may satisfy all ob- jective criteria regarding fit, quality, and appearance,a patient may be dissatisfied and occasionally intolerantof a denture based on subjective evaluation of comfort,functionality, and esthetics.Since patientevaluation cri-teria are difficult to quantify, the correlation betweendentist and patient opinions of dentures tends to bepoor.
These differences between clinician and pa-tient perception are important when the SDA patientis to receive treatment.Few clinical studies have assessed objectively patientoral comfort, typically the absence of pain or distress,masticatory ability, and the appearance of the dentition,in terms of arch length. When the oral comfort for SDA patients was compared with that for SDAs and distal ex-tension RPDs and for subjects with complete dentalarches, no significant differences were found betweenthe 3 groups with respect to pain or distress, and only 8% of the SDA subjects reported impaired masticatory ability.
It was noted that 20% of the SDA and RPDpatients were dissatisfied with the RPDs, and manpatients stopped wearing the RPD over longer periods. While an SDA can compromise oral comfort to a smallextent, it was still acceptable to the patients, and there were no indications that providing distal extensionRPDs enhanced oral comfort for SDA patients.
 Another study, based on patient questionnaires,found that when bilateral RPDs are used to restoreshortened mandibles, not only did patients prefer notto wear them, but there were indications of adverseeffects on the remaining teeth despite an improvedmasticatory ability.
Patients provided with distal can-tilever resin-bonded FPDs to restore the shortenedmandibular dental arch reported both better mastica-tory ability anda greater overall satisfaction than theRPD patients.
Clinical opinions regarding SDAs
Many patients with shortened dental arches receivetreatment, but there is no formal recognition of theSDA as a component in clinical treatment, and few papers in the literature addressing clinical attitudes tothe SDA in current therapy. A questionnaire adminis-teredbyBritishauthorsindicatedthattheSDAiswidely acceptedbut not widely practiced in the UnitedKingdom.
The outcome of SDA therapy (SDAT) was found to be acceptable in approximately 82% of patients in terms of patient oral function, comfort, and well-being. Some 88% of respondents to the question-naire reported prescribing SDAT during the previous5years,although37%oftheparticipantsreportedaneedto extend shortened dental arches following SDAT.
DECEMBER 2004 533

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